Client Intake Forms - Dream Center

[Pages:17]Client Intake Forms

2301 Bellevue Ave. Los Angeles, CA 90026 213-273-7171 (Office)

213-273-7227 (Fax) Revised: August 2012

Dear Concerned Individual, Friend or Family Member;

I've never liked the idea of having to send people away to some strange place to fix them, but having worked with people who are struggling with life-controlling issues for years, I realize that, for a season, sometimes people need to be removed from their surroundings in order to get a "fresh start" and begin to heal the hurts in their life.

I can't even begin to imagine how difficult a decision this is for you. I encourage you to investigate all of the options that are available to you and prayerfully seek God concerning this decision. Also, hopefully, by this point, you've had a chance to talk to one of our Intake Counselors and obtain some basic information about the program.

DC Discipleship is an intense one-year program designed to help individuals between the ages of 18 and 59 who are struggling with alcohol, drug abuse or any other lifecontrolling problems. We offer a faith-based discipleship/recovery curriculum designed to help our students realize that we can achieve spiritual success if we are properly disciplined. Our motto is the great commission--Matthew 28:19... "Therefore, go and make disciples..."

Our vision is to produce graduates, who become a successful, productive and functional part of society. Many of the people who come through this program really do change, but we can't force the change to happen, they have to want it.

The process is long, so please don't expect a person to change overnight, but do expect change. This program also teaches people how to make right choices. It is usually because of wrong choices that people end up in a facility like this.

So please be patient as we work through this process. Also, expect your loved one to say negative things about this program. Many will do this in hopes of getting you to change your mind and allow them to come back home early. Please, just trust us and know that we are doing all we can to help them to heal and deal with the issues that got them to this point in their life. We want to return your friend or loved one to you as a whole, healed person.

Please realize that we have a limited number of spaces available, so please be patient but persistent. The following page outlines the application process.

Although I hope you won't need our services, I do look forward to working with you in the eventuality that you, your friend or family member needs a change of environment in order to find his or her identity and purpose in life. In the spirit of The Dream Center, we are here to help you and your family dream again.

Sincerely,

Michael Conner Executive Director DC Discipleship

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Application Procedure 1) Call our office at 213-273-7171 and request an application. 2) Please fill in all the blanks. If something does not apply to you then put "NA" in the

blank space. 3) You may fax the completed application to 213-273-7227 of mail it to the address

below; DCD Attn: Intake Office 2301 Bellevue Ave Los Angeles, CA 90026

4) Once we receive a copy of the application, you will be contacted to let you know if you qualify for the program and when you may come in or if you have been placed on a waiting list. You may contact us weekly to see how long you have to wait for a space to open up.

5) When you are contacted by our Intake Office please be prepared to give us a date as to when you expect to be here.

6) Bring the items listed on the last page, "What to Bring?"

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Client Intake Form

Personal Information

Last Name:

First Name:

Date of Birth: ID Number:

List: Type of ID, State & Number

Spouse Name: Social Security #:

Address: City Home Phone:

Homeless: Yes No

State:

Zip Code:

Work Phone:

Cell Phone:

Fax:

Age:

Sex: Male Female Height:

Weight:

Religion:

Race/Ethnicity:

Marital Status:

Single

Married

Spouse Name (If applicable):

Divorced

Widowed

Family Status: Has minor Children Has Adult Children No Children

Email Address:

Have you been in DCD before? Yes No If yes, month/year:

Emergency Contact Person: Emergency Ph #:

FAMILY ONLY

Relationship:

Secondary #:

Emergency Address:

Do you have a car? Yes No program?

If yes who will take care of it while you are in the

Are you currently receiving any type of income? Yes No If yes, please explain:

Have you ever been in the military? Yes No If dishonorable discharge please explain.

Discharged? Yes No

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Education

Circle last year completed: Primary: 1 2 3 4 5 6 7 8 9 10 11 12 College: 1 2 3 4 +

Can you read and write? Yes No Can you speak English? Yes No Have you ever been in special education classes? Yes No

Religious Background

Do you believe in God? Yes No Uncertain

Have you ever accepted Jesus Christ as your Savior? Yes No Uncertain

Do you have a religious background? None Christian (Non-denominational)

Christian (Denominational)

Catholic Jehovah's Witness

Mormon

Muslim Agnostic/Atheist

Other (Please specify)

Legal History

Have you ever been arrested? Yes No How many times? _______________ If yes, give details:

Have you ever done jail time? Yes No If yes, what for and how long?

Are you on probation or parole? Yes No If yes, give probation or parole officer's contact information below:

Are you court ordered here? Yes No If yes, give contact information regarding your court case:

Do you have any legal charges pending? Yes No Where? What are the charges?

Do you think you may have any outstanding warrants? Yes No If yes, please explain:

Do you have any other pending legal matters that would require you to attend to in the next 90 days? Yes No If yes, give details below:

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Drug History

Have you ever used drugs? Yes No If yes, how old were you?

Why did you try them?

To help me deal with life.

Some of my family use drugs.

To escape reality.

Just for fun.

To fit in with my peers.

I'm bored.

My friends use drugs.

Curiosity.

To make physical pain go away.

Other: ________________________________

To make emotional pain go away.

Have you ever sold drugs? Yes No

Do you think you have a problem with drugs? Yes No Uncertain

Explain why or why not.

Since you've been using, what's the longest period of time that you've been sober?

Please fill out information below concerning your drug use.

Drug

(if you did not use drug listed leave blank, if drug is not listed fill in)

First Time

(How old were you or what month/year?)

Last Time

(Approximate date?)

Frequency

(How often did you use daily, weekly, monthly))

Alcohol

Amount Used

(How much did you use per day/week/month?)

Barbiturates

Benzodiazepines

Cocaine/Crack

Glue/Paint

Heroin

Inhalants(Snuffing)

LSD

Marijuana

MDMA (Ecstacy)

Meth

Mushrooms

PCP Prescription Drugs

Speed Tobacco Other:

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Medical History

Date of last physical exam: Results:

List any physical ailments or handicaps that you may have:

Date of last dental exam: Results:

List any dental problems you may have:

Date of last eye exam: Results:

Do you wear glasses? Yes No Do you wear contacts? Yes No

List anything that you may be allergic to:

Have you ever been: Diagnosed with ADD? Diagnosed with ADHD? Diagnosed with any Mental Disorder? Diagnosed with Tuberculosis? Diagnosed with Hepatitis A? Diagnosed with Hepatitis B? Diagnosed with Hepatitis C? Diagnosed with HIV Positive? Diagnosed with AIDS? Diagnosed with Herpes? Diagnosed with any STD? Diagnosed with Body Lice? Diagnosed with High Blood Pressure? Diagnosed with Heart Disease? Diagnosed with any other illnesses?

Yes No When? __________________ Yes No When? __________________ Yes No When? __________________ Yes No When? __________________ Yes No When? __________________ Yes No When? __________________ Yes No When? __________________ Yes No When? __________________ Yes No When? __________________ Yes No When? __________________ Yes No When? __________________ Yes No When? __________________ Yes No When? __________________ Yes No When? __________________ Yes No When? __________________

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Do you currently have any chronic medical conditions not listed above that require regular visits to the doctor? Yes No If yes, please explain:

Are you presently on any medication? Yes No (If yes, please list below and give reason for taking it.

Have you ever been admitted to a hospital? Yes No (If yes, please explain below.

Are you physically able to perform all assignments (you must be able to lift 25 lbs, be able to stand for long periods of time as well as climb up to 4 flights of stairs) as part of this program? Yes No If no, please explain: Have you ever been diagnosed with any mental condition? Yes No If yes, please explain:

Have you ever been under psychiatric care or been admitted to a mental health institution? Yes No If yes, please explain:

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